SPIROMETRY REFERRAL FORM - Fraser Health Authority

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COPD MAINTENANCE MEDICATION RECORDPatient Name: ___________________________ Date: ________________________________PHN: __________________________________ Date of Birth: __________________________Family Contact: __________________________ Phone #: _____________________________Physician: ______________________________ Phone #: _____________________________After Hours Phone #: ___________________________________________________________Patients: Take the following maintenance medications every day to help maintain control of yourCOPD symptoms.Physicians: Please fill in prescribed maintenance medications.Medication PrescribedHow Much toTakeWhen To TakeCOPD FLARE-UP MEDICATION RECORDPatients: Please fill in date when you start and finish your flare-up medications.Physicians: Please fill in prescribed flare-up (antibiotics & prednisone) medications.Medication Prescribed Start Date /Finish DateStart Date /Finish DateStart Date /Finish DateMake sure to take prescribed medication until all finished.
AVOIDLUNGATTACKSLUNG ATTACKS:The # 1 reason for hospitalizations in BCLung attacks often happen to people who have not yet been diagnosed with chronic obstructivepulmonary disease (COPD). A simple breathing test can identify your risk for COPDand prevent a COPD flare-up.Who should have a breathing test?People 40+ years of age who are current or ex-smokersand answer YES to any of the following questions:• Do you cough regularly?• Do you cough up phlegm regularly?• Do even simple chores make you short of breath?• Do you wheeze when you exert yourself, or at night?• Do you get frequent colds that persist longer than thoseof other people?Ask your doctor if you shouldhave a breathing test!For more information about COPD visit www.bclung.ca
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SPIROMETRY REFERRAL FORM - Fraser Health Authority

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